The GLP-1 access gap in type 2 diabetes isn’t coverage — it’s physician awareness | HSES 2026

GLP-1 medicines have become central to type 2 diabetes (T2D) management because they deliver both glycemic control and weight loss in a population where the two problems are usually linked — most T2D patients also carry overweight or obesity, and the drugs address both at once rather than treating them as separate conditions. The WHO’s first-ever global guideline on GLP-1 medicines for obesity, issued in December 2025, underscores how fast guideline-directed therapy for this drug class is moving; T2D-specific guidance has shifted in a similar direction, even as payer coverage criteria in many cases have not kept pace.

Head-to-head trial data (SUSTAIN 7, SURPASS-2) shows these agents outperforming older options and each other on HbA1c reduction and weight loss, with tirzepatide showing an edge over semaglutide. Pooled cardiovascular outcome trial data go further, showing roughly a 12% reduction in all-cause mortality and an 11% reduction in heart failure hospitalization, plus reduced nonfatal MI and stroke. The FLOW trial found a 24% reduction in a combined kidney/cardiovascular outcome with semaglutide, reinforcing a cardiorenal protective angle that’s increasingly part of how these drugs get positioned clinically — and covered.

Clinical guidance has moved toward treating GLP-1s as cardiorenal-protective therapy for a broad swath of T2D patients, but payer policies in many cases still reflect an older, narrower view of the drug as primarily a glucose-lowering agent, with utilization management built around that older framing. A patient whose doctor wants to prescribe based on the newer cardiorenal evidence can still hit a coverage denial built around older criteria.

At the Health System Executive Summit, Sophia Humphreys, PharmD, MHA, and David Kerr, MBChB, a diabetes and digital health physician, discuss where the clinical case for GLP-1s has outrun what payers are covering.

“We know from RCTs the drugs work,” Kerr said. “The question is, are people getting the drugs, and are they working in the real world?”

Real-world access barriers

That question is exactly what Sutter Health’s own data answered — and the answer wasn’t encouraging at baseline. Humphreys, who led Sutter’s formulary team during this work, described an internal review of more than 77,000 patients with T2D and a comorbid obesity diagnosis: only 7% had seen a diabetic educator or dietitian, and 49% hadn’t met their A1C goal.

“Quite a dire finding if you’re a formulary director,” she said.

The gap wasn’t really about the evidence — it was about whether physicians knew the guidance existed. A survey of 123 physicians, which was not publicly indexed online, (90% internal medicine and family medicine, 10% endocrinology, 5% cardiology) found that while 92% said they routinely evaluate patients on glucose-lowering agents, 54% were unaware of the EHR-embedded tool Sutter’s diabetes committee had built to support guideline-directed prescribing, and 59% were unfamiliar with the internal guideline altogether.

Layered on top of that awareness gap were demographic disparities in who actually got prescribed GLP-1s and SGLT2 inhibitors. Asian patients had the lowest prescribing rate in the cohort; Native Hawaiian and Pacific Islander patients had the highest. Younger women and Medicaid patients were more likely to be prescribed these drug classes than older patients, male patients, or patients on other insurance. None of that reflects a difference in who the guideline says should get these drugs — it reflects inconsistent application of it.

What health systems and payers need to change

Sutter’s fix was deceptively simple, Kerr noted. Take the guideline, embed it directly into the electronic health record so physicians don’t have to go looking for it, build awareness that the tool exists, then measure whether prescribing and outcomes actually shift. After that EHR-embedded “smart set” rolled out and the health system pushed physician education, dietitian referrals doubled to 14% of eligible patients. Over six months, more than 10,000 patients had both an A1C and BMI reduction following GLP-1 or SGLT2 treatment — a 0.8% A1C drop and 1 kg/m² BMI drop for the GLP-1 group, a 0.5% A1C drop and 0.8 kg/m² BMI drop for the SGLT2 group. In a separate, larger real-world cohort of more than 60,000 patients already on these drugs, Kerr said the same pattern held. When patients actually took the medication, A1C fell, reinforcing that the clinical trial data translates outside the trial setting.

One finding Kerr called a genuine surprise: the team expected non-white patients to see a smaller benefit, given well-documented disparities in cost, access, and health literacy. Instead, A1C fell across every racial and ethnic group in the cohort. “An unusual but a good news story,” he said — evidence that when a health system actually closes the awareness and referral gaps, equitable benefit follows.

Kerr also pointed to where this is heading next: pairing GLP-1 prescriptions with continuous glucose monitoring, since he cited new data showing the combination produces better A1C control than the drug alone, and floated the open question of whether CGM could reduce the high attrition rate many patients have on GLP-1s. He framed the broader stakes bluntly, noting that a person with diabetes spends less than 0.03% of the year face-to-face with a health professional — “the rest of the time, they’re on their own” — which is also why he expects primary care, not endocrinology, to end up responsible for most future diabetes technology (CGM, automated insulin delivery, smart insulin pens) as specialist capacity fails to scale with demand.